Medical surgical and nursing management of burn injury

1. MANAGEMENT OF
PATIENT WITH BURNS

2. Definition
• Injuries that result from direct contact or exposure to any
physical, thermal, chemical, electrical, or radiation
source are termed as Burns.

3. STATISTICS
 An estimated 265000 deaths every year are caused by burns.
 One of leading causes of disability-adjusted life-years (DALYs)
lost in low- and middle-income countries.

4. Problem Statement : India
 70 lakh burn injury cases annually
 Over 10,00,000 people are moderately or severely burnt every
year
 1.4 lakh people die of burn every year.
 Around 70% of all burn injuries occur in most productive age
group (15-35 years).
 Majority are women & children.
 As many as 80% of cases admitted are a result of accidents at
home (kitchen-related incidents)

5. CLASSIFICATION

6. Etiology
Based on Cause
o Thermal
o Electrical
o Chemical
o Radiation
o Inhalation

7. Thermal Injuries
• Most common
• Types : Dry & wet
Contact
• Direct contact with hot object (i.e. pan or iron)
• Anything that sticks to skin (i.e. tar, grease or foods)

8. Flame
oDirect contact with flame (dry heat)
o structural fires / clothing catching on fire

9. Electrical Burns
• Usually follows accidental contact with exposed object
conducting electricity
o Electrically powered devices
o Electrical wiring
o Power transmission lines
• Can also result from Lightning
• Damage depends on intensity of current

10. • Low-tension injuries(<1000 V)
o Low energy burns  Minimal damage to subcutaneous tissue
o Entry & Exit points – fingers  small deep burns
o AC  Tetany within muscles, cardiac arrest due to
interference with normal cardiac pacing
o High-tension injuries(>1000V)
• Earthed high tension lines  Arc over the patient  Flash
burn

11. • Severity depends upon:
owhat tissue current passes through (Low voltage/ High
voltage)
owidth or extent of the current pathway
oAC or DC
oduration of current contact

13. • Lightning
oHIGH VOLTAGE!!!
oInjury may result from
• Direct Strike
• Side Flash

14. Chemical Burns
• Usually associated with industrial exposure
• Accidental mishandling of household cleaners
Degree of tissue damage determined by
- Chemical nature of the agent
- Concentration of the agent
- Duration of skin contact
Acids- Eg- Formic acid,sulphuric acid
Alkalis - Eg. Lime, potassium hydroxide

15. Radiation Exposure
• Waves or particles of energy that are emitted from radioactive sources
• Alpha radiation
 Large, travel a short distance, minimal penetrating ability
 Can harm internal organs if inhaled, ingested or absorbed
• Beta radiation
 Small, more energy, more penetrating ability
 Usually enter through damaged skin, ingestion or inhalation

16. INHALATION
• Smoke and inhalation injury
carbon monoxide poisoning
inhalation injury above glottis
inhalation injury below glottis

17. According Depth of burn
• Superficial Partial-Thickness (First Degree burn)
cause-Sunburn
Low-intensity flash
Skin involvement- Epidermis
Symptoms- Reddened, Tingling, Pain that is soothed by cooling

18. Deep Partial-Thickness (Second
Degree)
Cause
• Scalds
• Flash flame
• Contact burns
• chemical
Skin involvement- Epidermis, upper dermis, portion of
deeper dermis
Manifestations- Blisters that are red, shiny. Severe pain caused by nerve injury
,mild to moderate edema
• Recovery in 2 to 4 weeks, some scarring and depigmentation contractures

19. Full-Thickness (Third Degree)
Cause-
• Flame
• Prolonged exposure to
• hot liquids
• Electric current
• Chemical
Skin involvement- Epidermis, entire dermis, and sometimes subcutaneous tissue;
may involve connective tissue, muscle,
and bone
Manifestations- Dry; pale white, Leathery, visible thrombosed
blood vessels
• Pain free, all skin elements and local nerve endings are destroyed, surgical
intervention required for healing

20. 4th Degree
E+D+S+muscles, tendons & bone

22. Extent of Body Surface Area
Injured
• RULE OF NINES,
• LUND AND BROWDER METHOD,
• PALM METHOD.

23. RULE OF NINES
• An estimation of the TBSA involved in a burn is simplified
by using the rule of nines
• The rule of nines is a quick way to calculate the extent of
burns. The system assigns percentages
in multiples of nine to major body surfaces

26. LUND AND BROWDER
METHOD
• A more precise method of estimating the extent of a burn is the
Lund and Browder method, which recognizes that the
percentage of TBSA of various anatomic parts
• By dividing the body into very small areas and providing an
estimate of the proportion of TBSA

28. PALM METHOD
• In patients with scattered burns, a method to estimate the
percentage
• of burn is the palm method. The size of the patient’s palm is
approximately 1% of TBSA.

29. Location of burn
• Burns to face, neck ,chest and back may inhibit respiratory
function due to mechanical obstruction secondary to
edema, eschar formation
• Burns to the ear, nose are susceptible to infection because
of poor blood supply
• Burns to buttocks, genitalia are susceptible to infection
because of contamination
• Burns on extremities cause circulatory compromise and
neurologic impairment.

30. Patient risk factors

31. Zones of burn injury

32. Zones of burn injury
• The inner zone (known as the zone of coagulation, where
cellular death occurs) sustains the most damage
o Necrotic area with cellular disruption
o Irreversible tissue damage
• The middle area, or zone of stasis, has a compromised blood
supply, inflammation, and tissue injury, Can survive or go on to
coagulative necrosis depending on wound environment
• The outer zone—the zone of hyperemia—sustains the least
damage

34. Pathophysiology
Burns> 30%
Cell lysis
increased capillary loss of skin barrier
permeability
Hemolysis Hyperkalemia inflamatory altered
Na,H20,Protien process
thermoreglatn
Haemo/myoglobinuria shift extravascular
Acute tubular neccrosis intravascular volume vasodilation hypothermia
ACUTE RENAL FAILURE BURNS SHOCK HYPOTENSION
ARRYTHMIAS
MODS

35. MANAGEMENT

36. Phases of burn management
• 1. emergent phase/resuscitative phase
• 2.Acute phase/ wound healing phase
• 3. Rehabilitative phase/Restorative phase

37. PRE HOSPITAL MANAGEMENT
• Rescuer to avoid injuring himself
• Remove patient from source of injury
• Stop burn process
• Burning clothing; jewelry, watches, belts to be removed
• Pour ample water on burnt area (not ice/ ice packs – skin injury
& hypothermia)

38.  Chemical burns:
Remove saturated clothing
Brush skin if agent is powder
Irrigation with copious amount water to be started and
continued in hospital
 Electrical burns:
Turn off the current
Use non-conductor item to separate from source

39. • Small thermal burns (<10% TBSA ) may be covered with
a clean, tap water-damped towel for patient comfort and
protection until definite medical care instituted
• Cooling of injured area within 1 minute helps minimize
the depth of injury
• If the burn injury is large (>10% TBSA) it is not advisable
to immerse the body part in cool water since doing so
might lead to extensive heat loss

40.  Do not break blisters.
 Do not apply lotions, powders, grease, ghee, gentian
violet, calamine lotion, toothpastes, butter and other
sticky agents over the burn wound.
 Prevent contamination: Wrap burn part in clean dry
sheet /cloth.
 Assess for life threatening injuries.

41. EMERGENT/RESUSCITATIVE
PHASE
• This phase may last 24-48 hours after injury
Resuscitation phase characterized by:
 Life-threatening airway problems
 Cardiopulmonary instability
 Hypovolemia
 Goal:
 Maintain vital organ function and perfusion

42. • Assess A B C
• ET intubation + assisted ventilation with 100% O2 if:
oOvert signs and symptoms of airway obstruction
(Progressive hoarseness)
oSuspected inhalational injury (smoke/ carbon
monoxide intoxication)
oUnconscious patient/ rapidly deteriorating patient
oAcute respiratory distress
oBurns of face & neck
oExtensive Burns (> 40% TBSA)

43. • Large gauge I.V catheter
• Central line Insertion
• Venesection
• Foleys catheter and NG tube placement
• Quick assessment of extent
• Tetanus prophylaxis (the only IM administered inj)
• Weigh the patient

44. • History
o Mechanism of injury
o Time of injury
o Surroundings (closed space/ chemicals)
• Physical examination
o Head to toe assessment
o Careful neurological examination (cerebral anoxia)
o Labs: CBC, electrolytes, BUN
o Pulmonary assessment: ABG, CXR, carboxyhemoglobin

45. • Pulse in extremities: manual/ doppler
• Loss of distal circulation
• Pallor/coolness/absent pulse/loss capillary refill/decreased
oxygen saturation
• Absent pulse: emergency escharotomy to release constrictive,
unyielding eschar

46. ESCHAROTOMY
• It is the surgical division of the nonviable skin and tissues , which
allows the cutaneous envelope to become more compliant
•Deep 2nd & 3rd degree circumferential burns
o Chest: To allow respiratory movement
o Limb: To restore circulation in limb with excess swelling under rigid
eschar
• Not in SC tissue  Exposes SC fat

48. FLUID RESUCITATION
• Parkland Formula
• Evan’s formula:
• Brooke formula

49. Parkland Formula
 Fluid of Choice
 Lactated Ringer’s (RL)
 NS can produce hyperchloremic acidosis
 4 ml x % of burn x weight (Kg) in 24 hours
 First ½ of total volume given in the first 8 hours
 Remaining ½ of total volume given over following 16 hours
 NEXT 24 HRS
 Total volume ½ of first day
 Colloids ( 0.5 ml / kg / % )
 5 % glucose to make up the rest

50. Brooke formula( modified)
 2 ml x % of burn x weight (Kg) in 24 hours
 First ½ of total volume given in the first 8 hours
 Remaining ½ of total volume given over following 16 hours
 NEXT 24 HRS
 Total volume ½ of first day
 Colloids (0 .3-0.5 ml / kg / % )

51. Evan’s formula
 Requirement for first 24 hrs
Colloids : 1ml/kg/% burn
Saline : 1ml/kg/% burn
D5 : 2000ml
 Requirement for second 24 hrs
½ of first 24 hrs

52. Assessment of Adequacy of
Fluid Resuscitation
• Monitor
o Urinary Output
• Adult: > 1 ml/ kg/ hr
o Daily Weight
o Vital Signs
• Heart rate and blood pressure
• CVP
• Level of Consciousness
o Laboratory values

53. RESUSCITATION FAILURE
• Delayed resuscitation
• Electric burns
• Inhalation injury
• Escharotomy
• Carbon monoxide poisoning
• Elderly patients

54. Wound care
• Wound care should be delayed until a patent airway,
adequate circulation and adequate fluid replacement
have been established.
• 2 types of wound treatment used to control infection
1. open method
2. multiple dressing change method

55. Closed method

56. Antimicrobial Agent
• Silvadene (silver sulfadiazine)1% cream-
• Most bactericidal agent
• Minimal penetration of eschar
• Mafenide acetate 5% to 10% (Sulfamylon) hydrophilic-based
cream
• Effective against gram-negative and gram-positive organisms
• Diffuses rapidly through eschar In 10% strength, it is the agent of choice
for electrical burns because of its ability to penetrate thick eschar

57. • Silver nitrate 0.5% aqueous solution-
• Bacteriostatic and fungicidal
• Does not penetrate eschar

58. Analgesia
• Morphine sulphate
• Fentanyl
• Methadone
• Haloperidol
• Lorazepam
• Midazolam

59. ACUTE PHASE
• Begins 48 to 72 hours after the burn injury.
• In this phase the extracellular fluid start mobilize and start
diuresis
• This phase is completes when wound is covered by skin grafts
or the wounds are healed
• This may take weeks or many months

60. • Eschar begins to separate fairly after injury
• Re epitheliazation begins at wound margin and appears
as red/pink scar tissue
• Hyponatremia/hypernatremia
• Hypokalemia/hyperkalemia
• Decreased hematocrit

61. Management
GOALS
• Prevention of infection and Wound care
• Excision and grafting
• Pain management
• Nutritional therapy
• Physical, psychosocial and occupational therapy

62. Prevention of infection and
Wound care
• Burn wounds are frequently monitored for bacterial colonization
• Wound swab cultures and invasive biopsies
• Cleanse and debride the area of necrotic tissue that would
promote bacterial growth

63. Debridement of the wound
• May be completed at the bedside or as a surgical procedure.
Types of Debridement:
Natural
• Body & bacterial enzymes dissolve eschar; takes a long time
Mechanical
• Sharp (scissors), Wet-to-Dry Dressings or Enzymatic Agents
Surgical

64. Wound/Skin Grafting
• If wounds are deep (full-thickness) or extensive,
spontaneous re-epithelialization is not possible.
Therefore, coverage of the burn wound is necessary by
using patients own skin or other methods.

65. TYPES
• Permanent Skin Grafts
Autografts
Cultured Epithelial Autografts (CEA)

66. Types
• TEMPORARY
 Biosynthetic-
Homograft / allograft (cadaveric)
heterograft/Xenograft (porcine)
 Artificial Skins (collagen based)
Trancyte/ Integra
 Synthetic
Biobrane/Opsite

67. Permanent skin graft
Autograft
•Harvested from pt
•Non-antigenic
•Less expensive
•Decreased risk of infection
•Can utilize meshing to cover large area
•Disadvantage : lack of sites and painful

70. Permanent skin graft
Cultured Epithelial Autografts (CEA)
• A small piece of pt’s skin is harvested and grown in a
culture medium (PDGF impregnated)
• Takes 3 weeks to grow enough for the first graft
• Very fragile; immobile for 10 days post grafting
• Useful for limited donor sites
• Disadvantage : very expensive; poor long term cosmetic
results and skin remains fragile for years

72. Temporary Skin Grafts
Biosynthetic
• Homograft/Allograft
• Live or cadaver human donors
• Fairly expensive/ all the function of skin
• Best infection control of all biologic coverings
• Disadvantage :
• Disease transmission (HBV & HIV)
• Antigenic: body rejects in 2 weeks
• Not always available
• Storage problems

73. Temporary Skin Grafts
BIOSYNTHETIC -Heterograft
• Xenograft
• Graft between 2 different species
• Porcine most common
• Fresh, frozen or freeze-dried (longer shelf life)
• Amenable to meshing & antimicrobial impregnation
• Antigenic: body rejects in 3-4 days
• Fairly inexpensive
• Disadvantage : Higher risk of infection

75. Temporary skin graft
Artificial Skins
• Transcyte:
oA collagen based dressing impregnated with newborn
fibroblasts.
• Integra:
oA collagen based product that helps to form a “neodermis”
ono anti-microbial property
Synthetic
• Any non-biologic dressing that will help prevent fluid & heat loss
oBiobrane, Xeroform, OpSite or Beta Glucan collagen matrix

77. Nutritional therapy
o High-protein & high-calorie diet
o Often requiring various supplements
o Routes:
• ORAL (BEST)
• Enteral
oGut is the preferred alternative route
oG-tube or J-tube (Head injury/ surgery/ unconscious)
• Parenteral
oTPN and PPN
oAssociated with an increased risk of infections

78. Physical and psychosocial care
• Active and passive ROM excercises should be performed all
joints
• Support and counselling
• Adjust with disabilities

79. Rehabilitation phase
• It starts when the patients burn wounds are healed and patient
is able to resume a level of selfcare activity
• This occur from weeks to months
• GOALS
• resuming a functional role in society and to accomplish
functional and cosmetic reconstructive surgery

80. • New skin starts to appear which is flat and pink
• Mature healing is reached in 6 months to 2 years
• Scarring can happen
discolouration
contour- skin is no longer flat or slightly elevate but
become elevated and enlarged above original burned area
• Apply water moisturisers and emolients to prevent dryness and
itching
• Protect from direct sunlight for 6 to 9 months

81. Complications
• EMERGENT PHASE
CVS- dysrhythmias and hypovolemic shock
Resp- upper RT injury, pulmonary edema, ARDS, pneumonia
urinary- Acute Tubular necrosis, ARF
ACUTE PHASE
infection – sepsis, septicemia ( pseudomonas)
G.I- Paralytic ileus, curlings ulcer
REHABILITATION PHASE
Contracture- abnormal condition of a joint characterised by flexion
and fixation

82. • Curling's ulcer
Curling ulcer is an acute gastric erosion resulting as a complication from
severe burns when reduced plasma volume leads to ischemia and cell
necrosis (sloughing) of the gastric mucosa.

85. Nursing management
• ASSESSMENT

86. NURSING DIAGNOSIS
• impaired gas exchange related to carbon monoxide poisoning, smoke
inhalation, and upper airway obstruction
• Ineffective airway clearance related to edema and effects of smoke
inhalation
• Fluid volume deficit related to increased capillary permeability and
evaporative losses from the burn wound
• Hypothermia related to loss of skin microcirculation and open wounds
• Pain related to tissue and nerve injury and emotional impact of injury
• Anxiety related to fear and the emotional impact of burn injury

87. • Fluid volume excess related to resumption of capillary integrity and fluid
shift from interstitial to intravascular compartment
• Risk for infection related to loss of skin barrier and impaired immune
response
• Altered nutrition, less than body requirements, related to hypermetabolism
and wound healing
• Impaired skin integrity related to open burn wounds
• Impaired physical mobility related to burn wound edema, pain, and joint
contractures
• Ineffective individual coping related to fear and anxiety, grieving, and forced
dependence on health care providers